Forms

Important note: Most forms on this page are in PDF formatting, unless otherwise noted. Please ensure you have the latest version of Adobe Reader on your system. See lower right of this page for a link to additional information.

Optum Forms - Administrative

California Grievance and IMR Forms

Clinician Application and Update Forms

Confidential Exchange of Information Form

Massachusetts Prior Authorization Forms (for State of Massachusetts ONLY)

Member Informed Consent Form (sample)

OHBS-CA Release of Information Form

Optum Release of Information Form

Patient Financial Responsibility Forms

Psychological Testing Request Forms

Site Audit Tools

Uniform Treatment Plans (UTP)
Fax completed UTP forms to 1-877-235-9905, unless requesting TX SB 58 Services. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011

Wellness Assessment Forms * does not apply to Unison membership

Wellness Assessments are available here, on the Forms page, at the secured user section, or by mail.

The Wellness Assessments here can be printed blank or, with the editable form, you can type in the information for the top section before printing the form.

Adult Wellness Assessment (English): blank or editable

Youth Wellness Assessment (English): blank or editable

Adult Wellness Assessment (Spanish): blank or editable

Youth Wellness Assessment (Spanish): blank or editable

WA Instruction Page:  English or Spanish

Sample completed WA: English or Spanish

WA Client Education Sheet

Wellness Assessments are also available at the secure transaction section of Provider Express for registered users!

Log in and click on the ALERT tab. Here you can print out Wellness Assessments that can be pre-populated with the name of the clinician* and member name.
*Note: A clinician number will be pre-populated on the form. For the confidentiality of those clinicians whose Tax ID is their social security number, all clinician numbers presented on these WA forms are Optum-assigned numbers.

Notes about the Wellness Assessment forms:

  • It is advised to download each Wellness Assessment rather than copy because photocopying will deteriorate the face quality of the form which could lead to technical difficulties in the ability of Optum to read the forms when you fax them to us.
  • There is only one Wellness Assessment form; it is the same one that is offered to members at the first and second time.
Optum Forms - Authorization

Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Colombia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)

Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)

Optum Forms - Claims

All outpatient and EAP claims should be submitted electronically via Provider Express or EDI. For faster claims reminbursement with less hassle, it is strongly encouraged that you sign up for electronic funds transfer (EFT) via our Electronic Payments & Statements (EPS) here.

Inpatient claims may be submitted through Electronic Data Interchange (EDI) through the clearinghouse of your choice.  For paper claim submission, facilities should use the industry standard UB-04 claim form using contracted revenue codes.  


Claims that need to be filed on paper should be done on the red 02/12 1500 Claim Form. Click to see a sample 1500 form, a listing of all Optum required fields, as well as the reverse side of the 1500 Claim Form.

Click here to learn where to submit Optum Claim forms

To receive copies of the 02/12 1500 Claim Form, contact:

NY State Out-of-Network Surprise Medical Bill Assignment of Benefits Form

Optum Forms - Clinical

Arizona Prior Authorization Request Process

California Grievance and IMR Forms

Confidential Exchange of Information Form

Coordination of Care Checklist

Disability Solutions Program Forms

Florida - FARS and CFARS

Long-Acting Injectable (LAI) Medication

Massachusetts Prior Authorization Forms

Nebraska Medicaid Forms

OHBS-CA Release of Information Forms

Ohio Prior Authorization Request Process

Optum Idaho Prior Authorization Forms

Optum Psychological Testing Request Forms

Screening Tools - the tools below are provided as a resource to aid in the screening of alcohol and drug use.

Transcranial Magnetic Stimulation (TMS) Authorizations Forms

Uniform Treatment Plans (UTP)
Fax completed UTP forms to 1-877-235-9905, unless requesting TX SB 58 Services. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011

Virginia Prior Authorization Forms

Wellness Assessment Forms * does not apply to Unison membership

Optum Forms - Disclosure Forms
Minnesota Care Management Center Forms